1451
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The effect of coronary angiography timing and use of cardiopulmonary bypass on acute kidney injury after coronary artery bypass graft surgery. J Thorac Cardiovasc Surg 2016; 152:254-261.e3. [DOI: 10.1016/j.jtcvs.2016.02.063] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 02/04/2016] [Accepted: 02/19/2016] [Indexed: 12/12/2022]
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1452
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Andò G, Costa F, Trio O, Oreto G, Valgimigli M. Impact of vascular access on acute kidney injury after percutaneous coronary intervention. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2016; 17:333-8. [DOI: 10.1016/j.carrev.2016.03.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 03/02/2016] [Accepted: 03/07/2016] [Indexed: 01/11/2023]
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1453
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Morgan DJR. Liberating the Kidney from Continuous Renal Replacement Therapy. Anaesth Intensive Care 2016; 44:442-3. [DOI: 10.1177/0310057x1604400420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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1454
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Darmon M, Vincent F, Canet E, Mokart D, Pène F, Kouatchet A, Mayaux J, Nyunga M, Bruneel F, Rabbat A, Lebert C, Perez P, Renault A, Meert AP, Benoit D, Hamidfar R, Jourdain M, Schlemmer B, Chevret S, Lemiale V, Azoulay E. Acute kidney injury in critically ill patients with haematological malignancies: results of a multicentre cohort study from the Groupe de Recherche en Réanimation Respiratoire en Onco-Hématologie. Nephrol Dial Transplant 2016; 30:2006-13. [PMID: 26597921 DOI: 10.1093/ndt/gfv372] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Cancer patients are at high risk for acute kidney injury (AKI), which is associated with high morbidity and mortality. We sought to appraise the incidence, risk factors, and outcome of AKI in a large multicentre cohort study of critically ill patients with haematological malignancies. METHODS We used a retrospective analysis of a prospectively collected database. The study was carried out in 17 university or university-affiliated centres in France and Belgium between 2010 and 2012. AKI was defined according to the Acute Kidney Injury Network (AKIN) definition. RESULTS Of the 1011 patients admitted into the intensive care unit (ICU) during the study period, 1009 were included in this study. According to the AKIN definition, 671 patients (66.5%) developed an AKI during their ICU stay, of which 258 patients (38.4%) were AKI stage 1, 75 patients (11.2%) AKI stage 2 and 338 patients (50.4%) AKI stage 3. After adjustment for confounders, main adverse risk factors of AKI were older age, severity [non-renal Sequential Organ Failure Assessment (SOFA)], history of hypertension, tumour lysis syndrome, exposure to nephrotoxic agents and myeloma. Hospital mortality was 44.3% in patients with AKI and 25.4% in patients without AKI (P < 0.0001). After adjustment for confounders, AKI was independently associated with hospital mortality [OR 1.65 (95% CI 1.19-2.29)]. Overall, 271 patients required renal replacement therapy (RRT), of whom 57.2% died during their hospital stay as compared with 31.2% (P < 0.0001) in those not requiring RRT. CONCLUSION Two-thirds of critically ill patients with haematological malignancies developed AKI. Hospital mortality in this population of patients developing AKI or requiring RRT is close to that in general ICU population.
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Affiliation(s)
| | | | | | | | | | | | - Julien Mayaux
- Pitié-Salpétrière University Hospital, Paris, France
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1455
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Arnaoutakis GJ, Vallabhajosyula P, Bavaria JE, Sultan I, Siki M, Naidu S, Milewski RK, Williams ML, Hargrove WC, Desai ND, Szeto WY. The Impact of Deep Versus Moderate Hypothermia on Postoperative Kidney Function After Elective Aortic Hemiarch Repair. Ann Thorac Surg 2016; 102:1313-21. [PMID: 27318775 DOI: 10.1016/j.athoracsur.2016.04.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 03/31/2016] [Accepted: 04/04/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND There remains concern that moderate hypothermic circulatory arrest (MHCA) with antegrade cerebral perfusion (ACP) may provide suboptimal distal organ protection compared with deep hypothermic circulatory arrest (DHCA) with retrograde cerebral perfusion (RCP). We compared postoperative acute kidney injury (AKI) in in patients who underwent elective hemiarch repair with either DHCA/RCP or MHCA/ACP. METHODS This was a retrospective review of all patients undergoing elective aortic hemiarch reconstruction for aneurysmal disease between 2009 and 2014. Patients were stratified according to the use of DHCA/RCP versus MHCA/ACP. The primary outcome was the occurrence of AKI at 48 hours, as defined by the Risk, Injury, Failure, Loss, End-Stage (RIFLE ) criteria. A multivariable logistic regression identified risk factors for AKI. RESULTS One hundred eighteen patients who underwent ACP and 471 patients who underwent RCP were included. The mean lowest temperature was 26.4°C in patients who underwent MHCA/ACP and 17.5°C in patients who underwent DHCA/RCP. Baseline demographics were similar except that patients who underwent DHCA/RCP were more likely to have peripheral arterial disease or bicuspid aortic valves. Cardiopulmonary bypass and aortic cross-clamp times were shorter in the MHCA/ACP group. AKI occurred in 19 (16.2%) patients who underwent MHCA/ACP and 67 (14.3%) patients who underwent DHCA/RCP. Four (0.8%) patients who underwent DHCA/RCP required postoperative dialysis. In-hospital mortality tended to increase with increasing RIFLE classification (RIFLE class-0 (No AKI) = 0.41%; Risk = 1.35%, and Injury = 10.0%; p = 0.09). On multivariable analysis, the lowest temperature and cerebral perfusion strategy were not significant predictors of AKI. Lower baseline glomerular filtration rate (GFR), lower preoperative ejection fraction, and longer cardiopulmonary bypass (CPB) time were independently associated with higher AKI. CONCLUSIONS We applied the sensitive RIFLE criteria to examine AKI in patients undergoing elective aortic hemiarch replacement for aneurysmal disease. Baseline renal dysfunction, lower ejection fraction, and longer CPB time are independent predictors of AKI. Compared with DHCA/RCP, our data suggest that an MHCA/ACP cerebral protection strategy does not appear to be associated with worse postoperative renal outcomes.
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Affiliation(s)
- George J Arnaoutakis
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Joseph E Bavaria
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary Siki
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Suveeksha Naidu
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rita K Milewski
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew L Williams
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - W Clark Hargrove
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
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1456
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Ravn B, Larsson A, Mårtensson J, Martling CR, Bell M. Intra-day variability of cystatin C, creatinine and estimated GFR in intensive care patients. Clin Chim Acta 2016; 460:1-4. [PMID: 27315745 DOI: 10.1016/j.cca.2016.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 06/09/2016] [Accepted: 06/13/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Markers of renal function are widely used in intensive care and sudden changes are important indicators of acute kidney injury. The problem is to distinguish between disease progression/improvement from the natural variation in the patient. The aim of the present study was thus to study the normal intraday variation in ICU patients. METHODS We studied the intra-day variation of creatinine, cystatin C and estimated GFR based on these two markers in 28 clinically stable ICU patients. RESULTS The median diurnal coefficient of variation sCV) for creatinine was 3.70% (1.92-9.25%) while the median CV for cystatin C was 3.66% (1.36-8.11%). The corresponding CVs for the estimated GFRs were 2.00% (0.89-9.82%) for eGFRcreatinine and 4.60% (1.65-10.24%) for eGFRcystc. CONCLUSIONS The eGFRcreatinine values in individual patients were clearly higher than the eGFRcystc values. The median CV for creatinine, cystatin C and the eGFR measurements were below 5% which means that 95% of the test results will vary by <10% between sampling times in stable ICU patients. Differences >10% between sampling times are thus likely to be an indication of changes in biomarker levels due to the disease/treatment.
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Affiliation(s)
- Bo Ravn
- Section of Anaesthesia and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, 17176 Stockholm, Sweden
| | - Anders Larsson
- Clinical Chemistry, Department of Medical Sciences, Uppsala University, 751 85 Uppsala, Sweden
| | - Johan Mårtensson
- Section of Anaesthesia and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, 17176 Stockholm, Sweden; Department of Intensive Care, Austin Hospital, Heidelberg, Melbourne, VIC 3084, Australia
| | - Claes-Roland Martling
- Section of Anaesthesia and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, 17176 Stockholm, Sweden
| | - Max Bell
- Section of Anaesthesia and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, 17176 Stockholm, Sweden.
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1457
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Caragata R, Wyssusek KH, Kruger P. Acute kidney injury following liver transplantation: a systematic review of published predictive models. Anaesth Intensive Care 2016; 44:251-61. [PMID: 27029658 DOI: 10.1177/0310057x1604400212] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Acute kidney injury is a frequent postoperative complication amongst liver transplant recipients and is associated with increased morbidity and mortality. This systematic review analysed the existing predictive models, in order to solidify current understanding. Articles were selected for inclusion if they described the primary development of a clinical prediction model (either an algorithm or risk score) to predict AKI post liver transplantation. The database search yielded a total of seven studies describing the primary development of a prediction model or risk score for the development of AKI following liver transplantation. The models span thirteen years of clinical research and highlight a gradual change in the definitions of AKI, emphasising the need to employ standardised definitions for subsequent studies. Collectively, the models identify a diverse range of predictive factors with several common trends. They emphasise the impact of preoperative renal dysfunction, liver disease severity and aetiology, metabolic risk factors as well as intraoperative variables including measures of haemodynamic instability and graft quality. Although several of the models address postoperative parameters, their utility in predictive modelling seems to be of questionable relevance. The common risk factors identified within this systematic review provide a minimum list of variables, which future studies should address. Research in this area would benefit from prospective, multi-site studies with larger cohorts as well as the subsequent internal and external validation of predictive models. Ultimately, the ability to identify patients at high risk of post-transplant AKI may enable early intervention and perhaps prevention.
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Affiliation(s)
- R Caragata
- Department of Anaesthesia, Princess Alexandra Hospital, Queensland, Australia
| | - K H Wyssusek
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - P Kruger
- Princess Alexandra Hospital, Queensland, Australia, The University of Queensland, School of Medicine, Herston Rd, 4006 Brisbane, Queensland, Australia
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1458
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Meijers B, De Moor B, Van Den Bosch B. The acute kidney injury e-alert and clinical care bundles: the road to success is always under construction. Nephrol Dial Transplant 2016; 31:1761-1763. [PMID: 27257275 DOI: 10.1093/ndt/gfw213] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 04/20/2016] [Indexed: 01/08/2023] Open
Affiliation(s)
- Björn Meijers
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.,Division of Nephrology, UZ Leuven, Leuven, Belgium
| | - Bart De Moor
- Department of Nephrology, Jessa Hospital, Hasselt, Belgium
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1459
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Grams ME, Sang Y, Coresh J, Ballew S, Matsushita K, Molnar MZ, Szabo Z, Kalantar-Zadeh K, Kovesdy CP. Acute Kidney Injury After Major Surgery: A Retrospective Analysis of Veterans Health Administration Data. Am J Kidney Dis 2016; 67:872-80. [PMID: 26337133 PMCID: PMC4775458 DOI: 10.1053/j.ajkd.2015.07.022] [Citation(s) in RCA: 209] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 07/11/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND Few trials of acute kidney injury (AKI) prevention after surgery have been conducted, and most observational studies focus on AKI following cardiac surgery. The frequency of, risk factors for, and outcomes after AKI following other types of major surgery have not been well characterized and may present additional opportunities for trials in AKI. STUDY DESIGN Observational cohort study. SETTING & PARTICIPANTS 3.6 million US veterans followed up from 2004 to 2011 for the receipt of major surgery (cardiac; general; ear, nose, and throat; thoracic; vascular; urologic; and orthopedic) and postoperative outcomes. FACTORS Demographics, health characteristics, and type of surgery. OUTCOMES Postoperative AKI defined by the KDIGO creatinine criteria, postoperative length of stay, end-stage renal disease, and mortality. RESULTS Postoperative AKI occurred in 11.8% of the 161,185 major surgery hospitalizations (stage 1, 76%; stage 2, 15%, stage 3 [without dialysis], 7%; and AKI requiring dialysis, 2%). Cardiac surgery had the highest postoperative AKI risk (relative risk [RR], 1.22; 95% CI, 1.17-1.27), followed by general (reference), thoracic (RR, 0.92; 95% CI, 0.87-0.98), orthopedic (RR, 0.70; 95% CI, 0.67-0.73), vascular (RR, 0.68; 95% CI, 0.64-0.71), urologic (RR, 0.65; 95% CI, 0.61-0.69), and ear, nose, and throat (RR, 0.32; 95% CI, 0.28-0.37) surgery. Risk factors for postoperative AKI included older age, African American race, hypertension, diabetes mellitus, and, for estimated glomerular filtration rate < 90mL/min/1.73m(2), lower estimated glomerular filtration rate. Participants with postoperative AKI had longer lengths of stay (15.8 vs 8.6 days) and higher rates of 30-day hospital readmission (21% vs 13%), 1-year end-stage renal disease (0.94% vs 0.05%), and mortality (19% vs 8%), with similar associations by type of surgery and more severe stage of AKI relating to poorer outcomes. LIMITATIONS Urine output was not available to classify AKI; cohort included mostly men. CONCLUSIONS AKI was common after major surgery, with similar risk factor and outcome associations across surgery type. These results can inform the design of clinical trials in postoperative AKI to the noncardiac surgery setting.
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Affiliation(s)
- Morgan E Grams
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD.
| | - Yingying Sang
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Josef Coresh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Shoshana Ballew
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
| | - Zoltan Szabo
- Department of Cardiothoracic Surgery and Cardiothoracic Anesthesia, Linköping University Hospital, Linköping, Sweden; Division of Cardiovascular Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research & Epidemiology, University of California Irvine Medical Center, Irvine, CA; Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN; Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN
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1460
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Intraoperative hypotension is associated with myocardial damage in noncardiac surgery. Eur J Anaesthesiol 2016; 33:450-6. [DOI: 10.1097/eja.0000000000000429] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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1461
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The authors reply. Pediatr Crit Care Med 2016; 17:580-1. [PMID: 27261656 DOI: 10.1097/pcc.0000000000000745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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1462
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Urine sodium concentration to predict fluid responsiveness in oliguric ICU patients: a prospective multicenter observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:165. [PMID: 27236480 PMCID: PMC4884621 DOI: 10.1186/s13054-016-1343-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 05/12/2016] [Indexed: 12/21/2022]
Abstract
Background Oliguria is one of the leading triggers of fluid loading in patients in the intensive care unit (ICU). The purpose of this study was to assess the predictive value of urine Na+ (uNa+) and other routine urine biomarkers for cardiac fluid responsiveness in oliguric ICU patients. Methods We conducted a prospective multicenter observational study in five university ICUs. Patients with urine output (UO) <0.5 ml/kg/h for 3 consecutive hours with a mean arterial pressure >65 mmHg received a fluid challenge. Cardiac fluid responsiveness was defined by an increase in stroke volume >15 % after fluid challenge. Urine and plasma biochemistry samples were examined before fluid challenge. We examined renal fluid responsiveness (defined as UO >0.5 ml/kg/h for 3 consecutive hours) after fluid challenge as a secondary endpoint. Results Fifty-four patients (age 51 ± 37 years, Simplified Acute Physiology Score II score 40 ± 20) were included. Most patients (72 %) were not cardiac responders (CRs), and 50 % were renal responders (RRs) to fluid challenge. Patient characteristics were similar between CRs and cardiac nonresponders. uNa+ (37 ± 38 mmol/L vs 25 ± 75 mmol/L, p = 0.44) and fractional excretion of sodium (FENa+) (2.27 ± 2.5 % vs 2.15 ± 5.0 %, p = 0.94) were not statistically different between those who did and those who did not respond to the fluid challenge. Areas under the receiver operating characteristic (AUROC) curves were 0.51 (95 % CI 0.35–0.68) and 0.56 (95 % CI 0.39–0.73) for uNa+ and FENa+, respectively. Fractional excretion of urea had an AUROC curve of 0.70 (95 % CI 0.54–0.86, p = 0.03) for CRs. Baseline UO was higher in RRs than in renal nonresponders (1.07 ± 0.78 ml/kg/3 h vs 0.65 ± 0.53 ml/kg/3 h, p = 0.01). The AUROC curve for RRs was 0.65 (95 % CI 0.53–0.78) for uNa+. Conclusions In the present study, most oliguric patients were not CRs and half were not renal responders to fluid challenge. Routine urinary biomarkers were not predictive of fluid responsiveness in oliguric normotensive ICU patients.
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1463
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Acute kidney injury in the perioperative period and in intensive care units (excluding renal replacement therapies). Anaesth Crit Care Pain Med 2016; 35:151-65. [PMID: 27235292 DOI: 10.1016/j.accpm.2016.03.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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1465
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Peng JM, Du B, Wang Q, Weng L, Hu XY, Wu CY, Shi Y. Dermatomyositis and Polymyositis in the Intensive Care Unit: A Single-Center Retrospective Cohort Study of 102 Patients. PLoS One 2016; 11:e0154441. [PMID: 27115138 PMCID: PMC4845982 DOI: 10.1371/journal.pone.0154441] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 04/13/2016] [Indexed: 12/27/2022] Open
Abstract
Introduction Patients with idiopathic inflammatory myopathies (IIMs) are sometimes complicated with life-threatening conditions requiring intensive care unit (ICU) admission. In the past, owing to the low incidence of IIM, little was known about such patients. Our aim was to investigate the clinical features and outcomes of these patients and identify their risk factors for mortality. Methods A retrospective study was performed of IIM patients admitted over an 8-year period to the medical ICU of a tertiary referral center in China. We collected data regarding demographic features, IIM-related clinical characteristics, reasons for admission, organ dysfunction, and outcomes. Independent predictors of ICU mortality were identified through multivariate logistic regression analysis. Results Of the 102 patients in our cohort, polymyositis (PM), dermatomyositis (DM), and clinically amyopathic dermatomyositis (CADM) accounted for 23.5%, 64.7%, and 11.7% respectively. The median duration from the onset of IIM to ICU admission was 4.3 months (interquartile range [IQR], 2.6–9.4 months). Reasons for ICU admission were infection alone (39.2%), acute exacerbation of IIM alone (27.5%), the coexistence of both (27.5%), or other reasons (5.8%). Pneumonia accounted for 97% of the infections; 63.2% of infections with documented pathogens were caused by opportunistic agents. Rapid progressive interstitial lung disease (RP-ILD) was responsible for 87.5% of acute exacerbation of IIM. The median Acute Physiology and Chronic Health Evaluation II (APACHE II) score on ICU day 1 was 17 (IQR 14–20). On ICU admission, acute respiratory failure (ARF) was the most common type (80.4%) of organ failure. The mortality rate in the ICU was 79.4%. Factors associated with increased ICU mortality included a diagnosis of DM (including CADM), a high APACHE II score, the presence of ARF, a decreased PaO2/FiO2 ratio, and a low lymphocyte count at the time of ICU admission. Conclusions The outcome of IIM patients admitted to the ICU was extremely poor. A diagnosis of DM/CADM, the presence and severity of ARF, and the lymphocyte counts at ICU admission were shown to be valuable for predicting outcome. Opportunistic infections and rapidly progressive interstitial lung disease warrant concern in treating these patients.
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Affiliation(s)
- Jin-Min Peng
- Department of Medical Intensive Care Unit, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Bin Du
- Department of Medical Intensive Care Unit, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Qian Wang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
- * E-mail:
| | - Li Weng
- Department of Medical Intensive Care Unit, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-Yun Hu
- Department of Medical Intensive Care Unit, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Chan-Yuan Wu
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Yan Shi
- Department of General Intensive Care Unit, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
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1466
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Acute kidney injury after cardiac surgery is not always related to coronary angiography timing. J Thorac Cardiovasc Surg 2016; 152:262-3. [PMID: 27107465 DOI: 10.1016/j.jtcvs.2016.03.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 03/10/2016] [Indexed: 11/20/2022]
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1467
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Bandak G, Grams ME. Kidney-Related Outcomes After Hospital-Associated Acute Kidney Injury: Even the Mildest Episodes Count. Am J Kidney Dis 2016; 67:716-8. [PMID: 27091012 DOI: 10.1053/j.ajkd.2016.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 02/03/2016] [Indexed: 11/11/2022]
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1468
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Huber W, Fuchs S, Minning A, Küchle C, Braun M, Beitz A, Schultheiss C, Mair S, Phillip V, Schmid S, Schmid RM, Lahmer T. Transpulmonary thermodilution (TPTD) before, during and after Sustained Low Efficiency Dialysis (SLED). A Prospective Study on Feasibility of TPTD and Prediction of Successful Fluid Removal. PLoS One 2016; 11:e0153430. [PMID: 27088612 PMCID: PMC4835077 DOI: 10.1371/journal.pone.0153430] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 03/29/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is common in critically ill patients. AKI requires renal replacement therapy (RRT) in up to 10% of patients. Particularly during connection and fluid removal, RRT frequently impairs haemodyamics which impedes recovery from AKI. Therefore, "acute" connection with prefilled tubing and prolonged periods of RRT including sustained low efficiency dialysis (SLED) has been suggested. Furthermore, advanced haemodynamic monitoring using trans-pulmonary thermodilution (TPTD) and pulse contour analysis (PCA) might help to define appropriate fluid removal goals. OBJECTIVES, METHODS Since data on TPTD to guide RRT are scarce, we investigated the capabilities of TPTD- and PCA-derived parameters to predict feasibility of fluid removal in 51 SLED-sessions (Genius; Fresenius, Germany; blood-flow 150 mL/min) in 32 patients with PiCCO-monitoring (Pulsion Medical Systems, Germany). Furthermore, we sought to validate the reliability of TPTD during RRT and investigated the impact of "acute" connection and of disconnection with re-transfusion on haemodynamics. TPTDs were performed immediately before and after connection as well as disconnection. RESULTS Comparison of cardiac index derived from TPTD (CItd) and PCA (CIpc) before, during and after RRT did not give hints for confounding of TPTD by ongoing RRT. Connection to RRT did not result in relevant changes in haemodynamic parameters including CItd. However, disconnection with re-transfusion of the tubing volume resulted in significant increases in CItd, CIpc, CVP, global end-diastolic volume index GEDVI and cardiac power index CPI. Feasibility of the pre-defined ultrafiltration goal without increasing catecholamines by >10% (primary endpoint) was significantly predicted by baseline CPI (ROC-AUC 0.712; p = 0.010) and CItd (ROC-AUC 0.662; p = 0.049). CONCLUSIONS TPTD is feasible during SLED. "Acute" connection does not substantially impair haemodynamics. Disconnection with re-transfusion increases preload, CI and CPI. The extent of these changes might be used as a "post-RRT volume change" to guide fluid removal during subsequent RRTs. CPI is the most useful marker to guide fluid removal by SLED.
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Affiliation(s)
- Wolfgang Huber
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
- * E-mail:
| | - Stephan Fuchs
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Andreas Minning
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Claudius Küchle
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Marlena Braun
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Analena Beitz
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Caroline Schultheiss
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Sebastian Mair
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Veit Phillip
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Sebastian Schmid
- Klinik für Anaesthesiologie, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Roland M. Schmid
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Tobias Lahmer
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
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1469
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Zhou J, Li Y, Tang Y, Liu F, Yu S, Zhang L, Zeng X, Zhao Y, Fu P. Effect of acute kidney injury on mortality and hospital stay in patient with severe acute pancreatitis. Nephrology (Carlton) 2016; 20:485-91. [PMID: 25726708 DOI: 10.1111/nep.12439] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2015] [Indexed: 02/05/2023]
Abstract
AIM Severe acute pancreatitis (SAP) is believed to be a major risk factor leading to acute kidney injury (AKI) among critically ill patients, but little is known about SAP-induced AKI. We study the incidence of AKI defined by the Acute Kidney Injury Network (AKIN) criteria and the risk factors associated with outcomes among SAP-induced AKI patients. METHOD We conducted a multicenter retrospective study of critically ill SAP-induced AKI patients during the period August 2009 to June 2013. Data on enrolled patients were retrieved from electronic records. Univariate and multiple regression analyses were performed. RESULTS Among a total of 414 SAP patients admitted to intensive care units(ICU), 287 (69.3%) developed AKI during their ICU stay, with 16.7%, 18.4%, and 34.3% classified as AKI stage I,II, and III, respectively. SAP-induced AKI patients experienced a significantly higher ICU mortality than those without AKI. The risk factors associated with ICU mortality among SAP-induced AKI patients included ACS (odds ratio (OR) 10.58), RRT (OR 3.31), sepsis (OR 2.46), CTSI (OR 3.01), APACHE II score (OR 1.82), AKI III (OR 1.38), ICU-length-of-stay (OR 1.04), and multi-organ failure. CONCLUSIONS The paper represents the first attempt to investigate the etiology and epidemiology of AKI following SAP under the AKIN criteria among critically ill patients. Several independent risk factors were found to be associated with ICU mortality for AKI patients. The findings may pinpoint crucial therapeutic measures for preventing AKI among a vulnerable population and for more effective management of SAP-induced AKI to improve the quality of intensive care.
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Affiliation(s)
- Jiaojiao Zhou
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yi Li
- Kidney Epidemiology and Cost Center, Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Yi Tang
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Fang Liu
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Shaobin Yu
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Ling Zhang
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Xiaoxi Zeng
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yuliang Zhao
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Ping Fu
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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1470
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Husi H, Human C. Molecular determinants of acute kidney injury. J Inj Violence Res 2016; 7:75-86. [PMID: 26104320 PMCID: PMC4522318 DOI: 10.5249/jivr.v7i2.615] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Accepted: 07/10/2014] [Indexed: 12/18/2022] Open
Abstract
Background: Acute kidney injury (AKI) is a condition that leads to a rapid deterioration of renal function associated with impairment to maintain electrolyte and acid balance, and, if left untreated, ultimately irreversible kidney damage and renal necrosis. There are a number of causes that can trigger AKI, ranging from underlying conditions as well as trauma and surgery. Specifically, the global rise in surgical procedures led to a substantial increase of AKI incidence rates, which in turn impacts on mortality rates, quality of life and economic costs to the healthcare system. However, no effective therapy for AKI exists. Current approaches, such as pharmacological intervention, help in alleviating symptoms in slowing down the progression, but do not prevent or reverse AKI-induced organ damage. Methods: An in-depth understanding of the molecular machinery involved in and modulated by AKI induction and progression is necessary to specifically pharmacologically target key molecules. A major hurdle to devise a successful strategy is the multifactorial and complex nature of the disorder itself, whereby the activation of a number of seemingly independent molecular pathways in the kidney leads to apoptotic and necrotic events. Results: The renin-angiotensin-aldosterone-system (RAAS) axis appears to be a common element, leading to downstream events such as triggers of immune responses via the NFB pathway. Other pathways intricately linked with AKI-induction and progression are the tumor necrosis factor alpha (TNF α) and transforming growth factor beta (TGF β) signaling cascades, as well as a number of other modulators. Surprisingly, it has been shown that the involvement of the glutamatergic axis, believed to be mainly a component of the neurological system, is also a major contributor. Conclusions: Here we address the current understanding of the molecular pathways evoked in AKI, their interplay, and the potential to pharmacologically intervene in the effective prevention and/or progression of AKI.
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Affiliation(s)
- Holger Husi
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
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1471
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Abstract
OBJECTIVES Acute kidney injury is an independent risk factor for morbidity and mortality in critically ill children in the PICU. Neonates are a particularly vulnerable subgroup regarding acute kidney injury. The objectives were to define the prevalence of acute kidney injury to assess independent risk factors, for the development of acute kidney injury, and to determine the impact of acute kidney injury on outcomes in critically ill neonates without history of cardiac surgery. DESIGN A retrospective study of neonates (≤ 28 d old and ≥ 32 wk of gestational age) admitted to a tertiary PICU was conducted. Acute kidney injury was classified using the Kidney Disease: Improving Global Outcomes definition. SETTING PICU in a tertiary children's hospital. PATIENTS A total of 80 neonates (62% male neonates) with a median gestational age of 38 weeks (interquartile range, 37-39 wk) were reviewed. INTERVENTION None. MEASUREMENT AND MAIN RESULTS Acute kidney injury was found in 35% (n = 28) of neonates. Fourteen (50%) reached stage I, 8 (29%) stage II, and 6 (21%) stage III acute kidney injury. Younger age was associated with acute kidney injury (p = 0.016; odds ratio, 0.93; CI, 0.88-0.98). In regression analysis adjusted for age and gender, bacteremia (p = 0.014; odds ratio, 5.4; CI, 1.4-20.4) and maximum sodium concentration (p = 0.02; odds ratio, 1.12; CI, 1.02-1.24) were associated with acute kidney injury. Mortality (p = 0.03) and length of mechanical ventilation (p = 0.001) were significantly higher in neonates with acute kidney injury compared with those without acute kidney injury. In an adjusted regression model, stages 2 and 3 combined were associated with increased mortality (p = 0.02; odds ratio, 5.64; CI, 1.33-23.8), length of ventilation (p = 0.016; β, 12.2; CI, 2.39-22.0), and length of stay (p = 0.049; β, 12.2; CI, 0.073-24.3). CONCLUSIONS Acute kidney injury is common in neonates not requiring cardiac surgery and is associated with increased morbidity and mortality. Age, bacteremia, and maximum sodium concentration are independently associated with the development of acute kidney injury in this population.
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1472
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Landoni G, Baiardo Redaelli M, Pisano A. Dopamine derivatives and acute kidney injury: the search for the magic bullet continues … and leads to new (magic?) targets. Nephrol Dial Transplant 2016; 31:512-514. [DOI: 10.1093/ndt/gfv366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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1473
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Palomba H, do Amaral Campos PPZ, Corrêa TD, de Carvalho FB, Westphal G, Gusmão D, Lisboa T, Grion CMC, de Assunção MSC. Defining and treating acute kidney injury patients in Brazilian intensive care units: Results from a cross-sectional nationwide survey. J Crit Care 2016; 34:33-7. [PMID: 27288607 DOI: 10.1016/j.jcrc.2016.03.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 03/01/2016] [Accepted: 03/23/2016] [Indexed: 01/22/2023]
Abstract
PURPOSE The purpose of the study is to characterize the practices of Brazilian intensivists toward acute kidney injury (AKI) definition and management. METHODS A cross-sectional survey was conducted among 36 Brazilian hospitals. RESULTS Of 731 ICU physicians invited to participate, 310 (42%) responded to the survey. Nearly half of the intensive care unit (ICU) physicians (146/310) do not apply AKIN and/or RIFLE definitions to their ICU patients. Most of the respondents prescribe intravenous fluids as a first-line therapeutic intervention for AKI patients. Although 38% of the surveyed physicians considered worsening of respiratory parameters to be the main criterion for stopping fluid infusion, only 15% considered daily net fluid balance as a criterion. Most of the respondents believed in the benefits of early renal replacement therapy (RRT) and considered worsening acidosis the most important criteria for starting early RRT. The main reason for a nephrologist referral was an urgently needed RRT. CONCLUSIONS Despite recent advances in AKI definition and management, most of the surveyed ICU physicians in Brazil have not incorporated them in their clinical practice. Important differences in the management of AKI patients were observed among Brazilian ICU physicians, which is relevant for educational interventions and future research.
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Affiliation(s)
- Henrique Palomba
- Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil.
| | | | | | | | - Glauco Westphal
- Intensive Care Unit, Centro Hospitalar Unimed, Joinville, Brazil.
| | - Dimitri Gusmão
- Hospital Geral Roberto Santos, Hospital Universitário Professor Edgars Santos, Salvador, Brazil.
| | - Thiago Lisboa
- Hospital de Clinicas/Hospital Santa Rita-Complexo Hospitalar Santa Casa-Porto Alegre, Porto Alegre, Brazil.
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1474
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Saito S, Uchino S, Takinami M, Uezono S, Bellomo R. Postoperative blood pressure deficit and acute kidney injury progression in vasopressor-dependent cardiovascular surgery patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:74. [PMID: 27013056 PMCID: PMC4806486 DOI: 10.1186/s13054-016-1253-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 02/23/2016] [Indexed: 12/29/2022]
Abstract
Background In vasopressor-dependent patients who had undergone cardiovascular surgery, we examined whether those with progression of acute kidney injury (AKI) had a greater difference (deficit) between premorbid and within-ICU hemodynamic pressure-related parameters compared to those without AKI progression. Methods We assessed consecutive adults who underwent cardiovascular surgery and who stayed in our ICU for at least 48 hours and received vasopressor support for more than 4 hours. We obtained premorbid and vasopressor-associated, time-weighted average values for hemodynamic pressure-related parameters (systolic [SAP], diastolic [DAP], and mean arterial pressure [MAP]; central venous pressure [CVP], mean perfusion pressure [MPP], and diastolic perfusion pressure [DPP]) and calculated deficits in those values. We defined AKI progression as an increase of at least one Kidney Disease: Improving Global Outcomes stage. Results We screened 159 patients who satisfied the inclusion criteria and identified 76 eligible patients. Thirty-six patients (47 %) had AKI progression. All achieved pressure-related values were similar between patients with or without AKI progression. However, deficits in DAP (P = 0.027), MPP (P = 0.023), and DPP (P = 0.002) were significantly greater in patients with AKI progression. Conclusions Patients with AKI progression had greater DAP, MPP, and DPP deficits compared to patients without AKI progression. Such deficits might be modifiable risk factors for the prevention of AKI progression.
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Affiliation(s)
- Shinjiro Saito
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, 3-19-18, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8471, Japan.
| | - Shigehiko Uchino
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, 3-19-18, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - Masanori Takinami
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, 3-19-18, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - Shoichi Uezono
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, 3-19-18, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Melbourne, VIC, 3084, Australia
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1475
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Qin W, Xie W, Yang X, Xia N, Yang K. Inhibiting microRNA-449 Attenuates Cisplatin-Induced Injury in NRK-52E Cells Possibly via Regulating the SIRT1/P53/BAX Pathway. Med Sci Monit 2016; 22:818-23. [PMID: 26968221 PMCID: PMC4792225 DOI: 10.12659/msm.897187] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Acute kidney injury (AKI) is quite common in the patients who frequently use the anticancer drug cisplatin. microRNAs (miRNAs) are powerful tools in modulating the expression of key factors in disease progression, but little is known about roles of miRNAs in AKI. This study explored the expression and function of miR-449 in cisplatin-induced AKI. Material/Methods Rat renal proximal tubular cell line NRK-52E was used for cisplatin treatment and miR-449 sponge transfection. MTT assay and flow cytometry were performed to detect cell viability and apoptosis in different cell groups. Protein expression of sirtuin 1 (SIRT1), acetylated p53, and BCL-associated X protein (BAX) was detected to deduce the possible regulatory mechanism of miR-449. Results Results showed that cisplatin treatment in NRK-52E cells significantly up-regulated miR-449 levels (P<0.05), inhibited cell viability (P<0.05), accelerated cell apoptosis (P<0.05), and changed SIRT1, acetylated p53, and BAX protein levels (P<0.01). However, inhibiting miR-449 by its sponge transfection in cisplatin-treated cells significantly promoted cell viability (P<0.05), suppressed cell apoptosis (P<0.05), elevated SIRT1 expression (P<0.01), and inhibited acetylated p53 and BAX protein levels (P<0.001). Conclusions These results indicate that inhibiting miR-449 allows the attenuation of cisplatin-induced injury in NRK-52E cells, suggesting that miR-449 is a potential target for treating AKI. miR-449 regulates the SIRT1/p53/BAX pathway, which may be its possible mechanism in modulating cell apoptosis of cisplatin-induced AKI. Further verification and a thorough understanding are necessary for targeting miR-449 in AKI treatment.
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Affiliation(s)
- Wen Qin
- Department of Pathology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China (mainland)
| | - Wei Xie
- Department of Reproductive Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China (mainland)
| | - Xi Yang
- Department of Geriatric Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China (mainland)
| | - Ning Xia
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China (mainland)
| | - Kunling Yang
- , Guangxi Medical University, Nanning, Guangxi, China (mainland)
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1476
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Palazuelos J, Rubio Alonso MÁ, Clares Montón P. Prognostic implications of baseline NT-proBNP before cardiac surgery. J Thorac Cardiovasc Surg 2016; 152:252-3. [PMID: 27056760 DOI: 10.1016/j.jtcvs.2016.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 03/04/2016] [Indexed: 10/22/2022]
Affiliation(s)
- Jorge Palazuelos
- Interventional Cardiac Unit, Cardiology Department, "Gómez Ulla" Central Defense University Hospital, Madrid, Spain.
| | | | - Patricia Clares Montón
- Interventional Cardiac Unit, Cardiology Department, "Gómez Ulla" Central Defense University Hospital, Madrid, Spain
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1477
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Weyker PD, Pérez XL, Liu KD. Management of Acute Kidney Injury and Acid-Base Balance in the Septic Patient. Clin Chest Med 2016; 37:277-88. [PMID: 27229644 DOI: 10.1016/j.ccm.2016.01.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute kidney injury (AKI) is an abrupt decrease in kidney function that takes place over hours to days. Sepsis is the leading cause of AKI and portends a particularly high morbidity and mortality, although the severity may vary from a transient rise in serum creatinine to end-stage renal disease. With regard to acid-base management in septic AKI, caution should be used with hyperchloremic crystalloid solutions, and dialysis is often used in the setting of severe acidosis. In the future, biomarkers may help clinicians identify AKI earlier and allow for potential interventions before the development of severe AKI.
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Affiliation(s)
- Paul D Weyker
- Division of Critical Care, Department of Anesthesia, Columbia University, 630 West, 160th Street, New York, NY 10032, USA
| | - Xosé L Pérez
- Intensive Care Medicine, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona 08907, Spain
| | - Kathleen D Liu
- Division of Critical Care Medicine, Department of Anesthesia, University of California, San Francisco, 533 Parnassus Avenue, San Francisco, CA 94143, USA.
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1478
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Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Fluid Management. Pediatr Crit Care Med 2016; 17:S35-48. [PMID: 26945328 DOI: 10.1097/pcc.0000000000000633] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE In this Consensus Statement, we review the etiology and pathophysiology of fluid disturbances in critically ill children with cardiac disease. Clinical tools used to recognize pathologic fluid states are summarized, as are the mechanisms of action of many drugs aimed at optimal fluid management. DATA SOURCES The expertise of the authors and a review of the medical literature were used as data sources. DATA SYNTHESIS The authors synthesized the data in the literature in order to present clinical tools used to recognize pathologic fluid states. For each drug, the physiologic rationale, mechanism of action, and pharmacokinetics are synthesized, and the evidence in the literature to support the therapy is discussed. CONCLUSIONS Fluid management is challenging in critically ill pediatric cardiac patients. A myriad of causes may be contributory, including intrinsic myocardial dysfunction with its associated neuroendocrine response, renal dysfunction with oliguria, and systemic inflammation with resulting endothelial dysfunction. The development of fluid overload has been associated with adverse outcomes, including acute kidney injury, prolonged mechanical ventilation, increased vasoactive support, prolonged hospital length of stay, and mortality. An in-depth understanding of the many factors that influence volume status is necessary to guide optimal management.
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1479
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Cha YS, Kim H, Kim J, Kim OH, Kim HI, Cha K, Lee KH, Hwang SO. Incidence and patterns of hemolytic anemia in acute dapsone overdose. Am J Emerg Med 2016; 34:366-9. [DOI: 10.1016/j.ajem.2015.09.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 09/08/2015] [Accepted: 09/09/2015] [Indexed: 11/25/2022] Open
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1480
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Egan RJ, Dewi F, Arkell R, Ansell J, Zouwail S, Scott-Coombes D, Stechman M. Does elective parathyroidectomy for primary hyperparathyroidism affect renal function? A prospective cohort study. Int J Surg 2016; 27:138-141. [DOI: 10.1016/j.ijsu.2016.01.072] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 01/07/2016] [Accepted: 01/21/2016] [Indexed: 11/25/2022]
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1481
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Sporek M, Dumnicka P, Gala-Bladzinska A, Ceranowicz P, Warzecha Z, Dembinski A, Stepien E, Walocha J, Drozdz R, Kuzniewski M, Kusnierz-Cabala B. Angiopoietin-2 Is an Early Indicator of Acute Pancreatic-Renal Syndrome in Patients with Acute Pancreatitis. Mediators Inflamm 2016; 2016:5780903. [PMID: 27022209 PMCID: PMC4789018 DOI: 10.1155/2016/5780903] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 01/19/2016] [Accepted: 01/28/2016] [Indexed: 01/27/2023] Open
Abstract
Within the first week of the disease, acute kidney injury (AKI) is among the most common causes of mortality in acute pancreatitis (AP). Recently, serum angiopoietin-2 (Ang-2) has been associated with hyperdynamic state of the systemic circulation. The aim of this study was to examine the associations between Ang-2 and the clinical AP severity during the first 72 hours of the disease, and organ disfunction, including AKI. Methods. Study included patients admitted to the surgery ward, diagnosed with AP. AKI was diagnosed according to KDIGO guidelines and renal failure according to modified Marshall scoring system. Ang-2 was determined in serum with ELISA. Results. AP was classified as mild (MAP) in 71% of patients, moderately severe (MSAP) in 22%, and severe (SAP) in 8%. During the first 72 hours of AP, 11 patients developed AKI and 6 developed renal failure. Ang-2 at 24, 48, and 72 hours following the onset of AP symptoms significantly predicted SAP and MSAP, as well as AKI and renal failure. Also, Ang-2 significantly correlated with acute phase proteins as well as with the indicators of renal disfunction. Conclusions. Serum Ang-2 may be a relevant predictor of AP severity, in particular of the development of AP-renal syndrome.
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Affiliation(s)
- Mateusz Sporek
- Surgery Department, The District Hospital, 22 Szpitalna Street, 34-200 Sucha Beskidzka, Poland
- Department of Anatomy, Faculty of Medicine, Jagiellonian University Medical College, 12 Kopernika Street, 31-034 Krakow, Poland
| | - Paulina Dumnicka
- Department of Medical Diagnostics, Faculty of Pharmacy, Jagiellonian University Medical College, 9 Medyczna Street, 30-688 Krakow, Poland
| | | | - Piotr Ceranowicz
- Department of Physiology, Faculty of Medicine, Jagiellonian University Medical College, 16 Grzegorzecka Street, 31-531 Krakow, Poland
| | - Zygmunt Warzecha
- Department of Physiology, Faculty of Medicine, Jagiellonian University Medical College, 16 Grzegorzecka Street, 31-531 Krakow, Poland
| | - Artur Dembinski
- Department of Physiology, Faculty of Medicine, Jagiellonian University Medical College, 16 Grzegorzecka Street, 31-531 Krakow, Poland
| | - Ewa Stepien
- Institute of Physics, Department of Medical Physics, Faculty of Physics, Astronomy and Applied Computer Science, Jagiellonian University, 11 Lojasiewicza Street, 30-348 Krakow, Poland
| | - Jerzy Walocha
- Department of Anatomy, Faculty of Medicine, Jagiellonian University Medical College, 12 Kopernika Street, 31-034 Krakow, Poland
| | - Ryszard Drozdz
- Department of Medical Diagnostics, Faculty of Pharmacy, Jagiellonian University Medical College, 9 Medyczna Street, 30-688 Krakow, Poland
| | - Marek Kuzniewski
- Department of Nephrology, Faculty of Medicine, Jagiellonian University Medical College, 15c Kopernika Street, 31-501 Krakow, Poland
| | - Beata Kusnierz-Cabala
- Department of Diagnostics, Chair of Clinical Biochemistry, Faculty of Medicine, Jagiellonian University Medical College, 15a Kopernika Street, 31-501 Krakow, Poland
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1482
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James MT, Hobson CE, Darmon M, Mohan S, Hudson D, Goldstein SL, Ronco C, Kellum JA, Bagshaw SM. Applications for detection of acute kidney injury using electronic medical records and clinical information systems: workgroup statements from the 15(th) ADQI Consensus Conference. Can J Kidney Health Dis 2016; 3:9. [PMID: 26925245 PMCID: PMC4768328 DOI: 10.1186/s40697-016-0100-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 01/05/2016] [Indexed: 12/16/2022] Open
Abstract
Electronic medical records and clinical information systems are increasingly used in hospitals and can be leveraged to improve recognition and care for acute kidney injury. This Acute Dialysis Quality Initiative (ADQI) workgroup was convened to develop consensus around principles for the design of automated AKI detection systems to produce real-time AKI alerts using electronic systems. AKI alerts were recognized by the workgroup as an opportunity to prompt earlier clinical evaluation, further testing and ultimately intervention, rather than as a diagnostic label. Workgroup members agreed with designing AKI alert systems to align with the existing KDIGO classification system, but recommended future work to further refine the appropriateness of AKI alerts and to link these alerts to actionable recommendations for AKI care. The consensus statements developed in this review can be used as a roadmap for development of future electronic applications for automated detection and reporting of AKI.
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Affiliation(s)
- Matthew T James
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Charles E Hobson
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, Florida
| | - Michael Darmon
- Department of Intensive Care Medicine, Saint-Etienne University Hospital, Saint-Priest-En-Jarez, France
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY USA
| | - Darren Hudson
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Stuart L Goldstein
- Department of Pediatrics, Division of Pediatric Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH USA
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
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1483
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Siew ED, Basu RK, Wunsch H, Shaw AD, Goldstein SL, Ronco C, Kellum JA, Bagshaw SM. Optimizing administrative datasets to examine acute kidney injury in the era of big data: workgroup statement from the 15(th) ADQI Consensus Conference. Can J Kidney Health Dis 2016; 3:12. [PMID: 26925248 PMCID: PMC4768415 DOI: 10.1186/s40697-016-0098-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 01/14/2016] [Indexed: 02/08/2023] Open
Abstract
PURPOSE OF REVIEW The purpose of this review is to report how administrative data have been used to study AKI, identify current limitations, and suggest how these data sources might be enhanced to address knowledge gaps in the field. OBJECTIVES 1) To review the existing evidence-base on how AKI is coded across administrative datasets, 2) To identify limitations, gaps in knowledge, and major barriers to scientific progress in AKI related to coding in administrative data, 3) To discuss how administrative data for AKI might be enhanced to enable "communication" and "translation" within and across administrative jurisdictions, and 4) To suggest how administrative databases might be configured to inform 'registry-based' pragmatic studies. SOURCE OF INFORMATION Literature review of English language articles through PubMed search for relevant AKI literature focusing on the validation of AKI in administrative data or used administrative data to describe the epidemiology of AKI. SETTING Acute Dialysis Quality Initiative (ADQI) Consensus Conference September 6-7(th), 2015, Banff, Canada. PATIENTS Hospitalized patients with AKI. KEY MESSAGES The coding structure for AKI in many administrative datasets limits understanding of true disease burden (especially less severe AKI), its temporal trends, and clinical phenotyping. Important opportunities exist to improve the quality and coding of AKI data to better address critical knowledge gaps in AKI and improve care. METHODS A modified Delphi consensus building process consisting of review of the literature and summary statements were developed through a series of alternating breakout and plenary sessions. RESULTS Administrative codes for AKI are limited by poor sensitivity, lack of standardization to classify severity, and poor contextual phenotyping. These limitations are further hampered by reduced awareness of AKI among providers and the subjective nature of reporting. While an idealized definition of AKI may be difficult to implement, improving standardization of reporting by using laboratory-based definitions and providing complementary information on the context in which AKI occurs are possible. Administrative databases may also help enhance the conduct of and inform clinical or registry-based pragmatic studies. LIMITATIONS Data sources largely restricted to North American and Europe. IMPLICATIONS Administrative data are rapidly growing and evolving, and represent an unprecedented opportunity to address knowledge gaps in AKI. Progress will require continued efforts to improve awareness of the impact of AKI on public health, engage key stakeholders, and develop tangible strategies to reconfigure infrastructure to improve the reporting and phenotyping of AKI. WHY IS THIS REVIEW IMPORTANT?: Rapid growth in the size and availability of administrative data has enhanced the clinical study of acute kidney injury (AKI). However, significant limitations exist in coding that hinder our ability to better understand its epidemiology and address knowledge gaps. The following consensus-based review discusses how administrative data have been used to study AKI, identify current limitations, and suggest how these data sources might be enhanced to improve the future study of this disease. WHAT ARE THE KEY MESSAGES?: The current coding structure of administrative data is hindered by a lack of sensitivity, standardization to properly classify severity, and limited clinical phenotyping. These limitations combined with reduced awareness of AKI and the subjective nature of reporting limit understanding of disease burden across settings and time periods. As administrative data become more sophisticated and complex, important opportunities to employ more objective criteria to diagnose and stage AKI as well as improve contextual phenotyping exist that can help address knowledge gaps and improve care.
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Affiliation(s)
- Edward D Siew
- Tennessee Valley Health System (TVHS), Nashville Veterans Affairs Hospital, Nashville, TN USA ; Vanderbilt University Medical Center, Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Diseases (VCKD), 1161 21st Avenue South, MCN S3223, Nashville, TN 37232 USA
| | - Rajit K Basu
- Cincinnati Children's Hospital, Department of Pediatrics, Division of Critical Care Medicine and the Center for Acute Care Nephrology, The University of Cincinnati, Cincinnati, OH USA
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center Center and Sunnybrook Research Institute; Department of Anesthesia and Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON Canada
| | - Andrew D Shaw
- Vanderbilt University Medical Center Department of Anesthesiology, Nashville, TN USA
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH USA
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute (IRRIV), San Bortolo Hospital, Vicenza, Italy
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Alberta, Canada
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1484
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Conroy AL, Hawkes M, Elphinstone RE, Morgan C, Hermann L, Barker KR, Namasopo S, Opoka RO, John CC, Liles WC, Kain KC. Acute Kidney Injury Is Common in Pediatric Severe Malaria and Is Associated With Increased Mortality. Open Forum Infect Dis 2016; 3:ofw046. [PMID: 27186577 PMCID: PMC4866565 DOI: 10.1093/ofid/ofw046] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 02/16/2016] [Indexed: 01/06/2023] Open
Abstract
Acute kidney injury is common in severe malaria and associated with short- and long-term mortality developing in 50% of cases after admission. Cystatin C and BUN are associated with the severity of AKI, are elevated at admission and predict mortality. Background. Acute kidney injury (AKI) is a well recognized complication of severe malaria in adults, but the incidence and clinical importance of AKI in pediatric severe malaria (SM) is not well documented. Methods. One hundred eighty children aged 1 to 10 years with SM were enrolled between 2011 and 2013 in Uganda. Kidney function was monitored daily for 4 days using serum creatinine (Cr). Acute kidney injury was defined using the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. Blood urea nitrogen (BUN) and Cr were assessed using i-STAT, and cystatin C (CysC) was measured by enzyme-linked immunosorbent assay. Results. Eighty-one (45.5%) children had KDIGO-defined AKI in the study: 42 (51.9%) stage 1, 18 (22.2%) stage 2, and 21 (25.9%) stage 3. Acute kidney injury evolved or developed in 50% of children after admission of hospital. There was an increased risk of AKI in children randomized to inhaled nitric oxide (iNO), with 47 (54.0%) of children in the iNO arm developing AKI compared with 34 (37.4%) in the placebo arm (relative risk, 1.36; 95% confidence interval [CI], 1.03–1.80). Duration of hospitalization increased across stages of AKI (P = .002). Acute kidney injury was associated with neurodisability at discharge in the children receiving placebo (25% in children with AKI vs 1.9% in children with no AKI, P = .002). Mortality increased across stages of AKI (P = .006) in the placebo arm, reaching 37.5% in stage 3 AKI. Acute kidney injury was not associated with neurodisability or mortality at discharge in children receiving iNO (P > .05 for both). Levels of kidney biomarkers were predictive of mortality with areas under the curves (AUCs) of 0.80 (95% CI, .65–.95; P = .006) and 0.72 (95% CI, .57–.87; P < .001), respectively. Admission levels of CysC and BUN were elevated in children who died by 6 months (P < .0001 and P = .009, respectively). Conclusions. Acute kidney injury is an underrecognized complication in young children with SM and is associated with increased mortality.
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Affiliation(s)
- Andrea L Conroy
- Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, University of Toronto, Canada; Department of Pediatrics, Indiana University, Indianapolis
| | - Michael Hawkes
- Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, University of Toronto, Canada; Division of Pediatric Infectious Diseases
| | - Robyn E Elphinstone
- Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health , University Health Network-Toronto General Hospital, University of Toronto , Canada
| | - Catherine Morgan
- Division of Pediatric Nephrology , University of Alberta , Edmonton, Canada
| | - Laura Hermann
- Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health , University Health Network-Toronto General Hospital, University of Toronto , Canada
| | - Kevin R Barker
- Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health , University Health Network-Toronto General Hospital, University of Toronto , Canada
| | | | - Robert O Opoka
- Department of Paediatrics and Child Health , Mulago Hospital and Makerere University , Kampala , Uganda
| | - Chandy C John
- Department of Pediatrics , Indiana University , Indianapolis
| | - W Conrad Liles
- Department of Medicine , University of Washington , Seattle
| | - Kevin C Kain
- Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, University of Toronto, Canada; Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Canada
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1485
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Zhang A, Cai Y, Wang PF, Qu JN, Luo ZC, Chen XD, Huang B, Liu Y, Huang WQ, Wu J, Yin YH. Diagnosis and prognosis of neutrophil gelatinase-associated lipocalin for acute kidney injury with sepsis: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:41. [PMID: 26880194 PMCID: PMC4754917 DOI: 10.1186/s13054-016-1212-x] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 01/29/2016] [Indexed: 01/25/2023]
Abstract
Background Neutrophil gelatinase-associated lipocalin (NGAL) has been identified as an early biomarker for prediction of acute kidney injury (AKI). However, the utility of NGAL to predict the occurrence of AKI in septic patients remains controversial. We performed a systematic review and meta-analysis to evaluate the evidence on diagnosis of sepsis AKI and the prediction of other clinical outcomes. Method The MEDLINE, EMBASE, Cochrane Library, Wanfang, and CNKI databases were systematically searched up to August 19, 2015. Quality assessment was applied by using the Quality Assessment for Studies of Diagnostic Accuracy (QUADAS-2) tool. The diagnostic performance of NGAL for the prediction of AKI in sepsis was evaluated using pooled estimates of sensitivity, specificity, likelihood ratio, and diagnostic odds ratio (DOR), as well as summary receiver operating characteristic curves (SROC). Results Fifteen studies with a total of 1,478 patients were included in the meta-analysis. For plasma NGAL, the pooled sensitivity and specificity with corresponding 95 % confidence intervals (CI) were 0.83 (95 % CI: 0.77 − 0.88) and 0.57 (95 % CI: 0.54 − 0.61), respectively. The pooled positive likelihood ratio (PLR) was 3.10 (95 % CI: 1.57 − 6.11) and the pooled negative likelihood ratio (NLR) was 0.24 (95 % CI: 0.13 − 0.43). The pooled DOR was 14.72 (95 % CI: 6.55 − 33.10) using a random effects model. The area under the curve (AUC) for SROC to summarize diagnostic accuracy was 0.86. For urine NGAL, the pooled sensitivity, specificity, PLR, NLR, DOR, and AUC values were 0.80 (95 % CI: 0.77 − 0.83), 0.80 (95 % CI: 0.77 − 0.83), 4.42 (95 % CI: 2.84 − 6.89), 0.21 (95 % CI: 0.13 − 0.35), 24.20 (95 % CI: 9.92 − 59.05) and 0.90, respectively. Significant heterogeneity was explored as a potential source. There was no notable publication bias observed across the eligible studies. NGAL for prediction of renal replacement therapy (RRT) and mortality associated with AKI in septic patients were also evaluated. Conclusion To a certain extent, NGAL is not only an effective predictive factor for AKI in the process of sepsis, but also shows potential predictive value for RRT and mortality. However, future trials are needed to clarify this controversial issue.
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Affiliation(s)
- An Zhang
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
| | - Ying Cai
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
| | - Peng-Fei Wang
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
| | - Jian-Ning Qu
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
| | - Zhen-Chun Luo
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
| | - Xiao-Dong Chen
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
| | - Bin Huang
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
| | - Yi Liu
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
| | - Wen-Qi Huang
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
| | - Jing Wu
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
| | - Yue-Hui Yin
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
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1486
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Grams ME, Sang Y, Coresh J, Ballew SH, Matsushita K, Levey AS, Greene TH, Molnar MZ, Szabo Z, Kalantar-Zadeh K, Kovesdy CP. Candidate Surrogate End Points for ESRD after AKI. J Am Soc Nephrol 2016; 27:2851-9. [PMID: 26857682 DOI: 10.1681/asn.2015070829] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 01/06/2016] [Indexed: 11/03/2022] Open
Abstract
AKI, a frequently transient condition, is not accepted by the US Food and Drug Association as an end point for drug registration trials. We assessed whether an intermediate-term change in eGFR after AKI has a sufficiently strong relationship with subsequent ESRD to serve as an alternative end point in trials of AKI prevention and/or treatment. Among 161,185 United States veterans undergoing major surgery between 2004 and 2011, we characterized in-hospital AKI by Kidney Disease Improving Global Outcomes creatinine criteria and decline in eGFR from prehospitalization to postdischarge time points and quantified associations of these values with ESRD and mortality over a median of 3.8 years. An eGFR decline of ≥30% at 30, 60, and 90 days after discharge occurred in 3.1%, 2.5%, and 2.6%, of survivors without AKI and 15.9%, 12.2%, and 11.7%, of survivors with AKI. For patients with in-hospital AKI compared with those with no AKI and stable eGFR, a 30% decline in eGFR at 30, 60, and 90 days after discharge demonstrated adjusted hazard ratios (95% confidence intervals) of ESRD of 5.60 (4.06 to 7.71), 6.42 (4.76 to 8.65), and 7.27 (5.14 to 10.27), with corresponding estimates for 40% decline in eGFR of 6.98 (5.21 to 9.35), 8.03 (6.11 to 10.56), and 10.95 (8.10 to 14.82). Risks for mortality were smaller but consistent in direction. A 30%-40% decline in eGFR after AKI could be a surrogate end point for ESRD in trials of AKI prevention and/or treatment, but additional trial evidence is needed.
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Affiliation(s)
- Morgan E Grams
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Departments of Epidemiology and
| | | | - Josef Coresh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Departments of Epidemiology and Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | | | | | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Tom H Greene
- Division of Clinical Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Zoltan Szabo
- Department of Cardiothoracic Surgery and Cardiothoracic Anesthesia, Linköping University Hospital, Linköping, Sweden; Division of Cardiovascular Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology and Division of Nephrology and Hypertension, University of California Irvine Medical Center, Irvine, California; and
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee; Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
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1487
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Dexmedetomidine Is Associated With Lower Incidence of Acute Kidney Injury After Congenital Heart Surgery. Pediatr Crit Care Med 2016; 17:128-34. [PMID: 26673841 DOI: 10.1097/pcc.0000000000000611] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Recent data have suggested an association between the use of dexmedetomidine and a decreased incidence of acute kidney injury in adult patients after cardiopulmonary bypass. However, no study has focused on this association among pediatric populations where the incidence of acute kidney injury is particularly high and of critical significance. The primary objective of this study was to assess the relationship between the use of postoperative dexmedetomidine and the incidence of acute kidney injury in pediatric patients undergoing cardiopulmonary bypass. The secondary objective was to determine whether there was an association between dexmedetomidine use and duration of mechanical ventilation or cardiovascular ICU stay. DESIGN Single-center retrospective matched cohort study. SETTING A 20-bed quaternary cardiovascular ICU in a university-based pediatric hospital in California. PATIENTS Children less than 18 years old admitted after cardiac surgery with cardiopulmonary bypass between January 1, 2012, and May 31, 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Data from a cohort of 102 patients receiving dexmedetomidine during the first postoperative day after cardiac surgery were compared to an age- and procedure-matched cohort not receiving dexmedetomidine. Cohorts had similar baseline and demographic characteristics. Patients receiving dexmedetomidine were less likely to develop acute kidney injury (24% vs 36%; odds ratio, 0.54; 95% CI, 0.29-0.99; p = 0.046). After adjusting for age, bypass time, nephrotoxin use, and vasoactive inotropic score, the use of dexmedetomidine was associated with a lower incidence of acute kidney injury with adjusted odds ratio of 0.43 (95% CI, 0.27-0.98; p = 0.048). There was no difference between the cohorts with respect to the duration of mechanical duration (1 d each; p = 0.98) or cardiovascular ICU stays (5 vs 6 d; p = 0.91). CONCLUSIONS The use of a dexmedetomidine infusion in pediatric patients after congenital heart surgery was associated with a decreased incidence of acute kidney injury; however, it was not associated with changes in clinical outcomes. Further prospective study is necessary to validate these findings.
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1488
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A Double-Blinded, Randomized, Placebo-Controlled Clinical Trial of Aminophylline to Prevent Acute Kidney Injury in Children Following Congenital Heart Surgery With Cardiopulmonary Bypass. Pediatr Crit Care Med 2016; 17:135-43. [PMID: 26669642 PMCID: PMC4740222 DOI: 10.1097/pcc.0000000000000612] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Acute kidney injury occurs commonly in children following congenital cardiac surgery with cardiopulmonary bypass and has been associated with increased morbidity and mortality. Aminophylline, a methylxanthine nonselective adenosine receptor antagonist, has been effective in the management of acute kidney injury in certain populations. This study sought to determine whether postoperative administration of aminophylline attenuates acute kidney injury in children undergoing congenital cardiac surgery with cardiopulmonary bypass. DESIGN Single-center, double-blinded, placebo-controlled, randomized clinical trial. SETTING Tertiary center, pediatric cardiovascular ICU. PATIENTS A total of 144 children after congenital heart surgery with cardiopulmonary bypass. INTERVENTIONS Seventy-two patients were randomized to receive aminophylline and 72 patients received placebo. Study drug was administered every 6 hours for 72 hours. MEASUREMENTS AND MAIN RESULTS The primary outcome variable was the development of any acute kidney injury, defined by the serum creatinine criteria of the Kidney Diseases: Improving Global Outcomes. Secondary outcomes included the development of severe acute kidney injury, time between cardiovascular ICU admission and first successful extubation, percent fluid overload, total fluid balance, urine output, bioelectrical impedance, and serum neutrophil gelatinase-associated lipocalin. The unadjusted rate and severity of acute kidney injury were not different between groups; 43 of 72 (60%) of the treatment group and 36 of 72 (50%) of the placebo group developed acute kidney injury (p = 0.32). Stage 2/3 acute kidney injury occurred in 23 of 72 (32%) of the treatment group and 15 of 72 (21%) of the placebo group (p = 0.18). Secondary outcome measures also demonstrated no significant difference between treatment and placebo groups. Aminophylline administration was safe; no deaths occurred in either group, and rates of adverse events were similar (14% in the treatment group vs 18% in the placebo group; p = 0.30). CONCLUSIONS In this placebo-controlled randomized clinical trial, we found no effect of aminophylline to prevent acute kidney injury in children recovering from cardiac surgery performed with cardiopulmonary bypass. Future study of preoperative aminophylline administration to prevent acute kidney injury may be warranted.
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1489
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Joo EY, Moon YJ, Yoon SH, Chin JH, Hwang JH, Kim YK. Comparison of Acute Kidney Injury After Robot-Assisted Laparoscopic Radical Prostatectomy Versus Retropubic Radical Prostatectomy: A Propensity Score Matching Analysis. Medicine (Baltimore) 2016; 95:e2650. [PMID: 26844486 PMCID: PMC4748903 DOI: 10.1097/md.0000000000002650] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Acute kidney injury (AKI) is associated with extended hospital stay, a high risk of progressive chronic kidney diseases, and increased mortality. Patients undergoing radical prostatectomy are at increased risk of AKI because of intraoperative bleeding, obstructive uropathy, older age, and preexisting chronic kidney disease. In particular, robot-assisted laparoscopic radical prostatectomy (RALP), which is in increasing demand as an alternative surgical option for retropubic radical prostatectomy (RRP), is associated with postoperative renal dysfunction because pneumoperitoneum during RALP can decrease cardiac output and renal perfusion. The objective of this study was to compare the incidence of postoperative AKI between RRP and RALP.We included 1340 patients who underwent RRP (n = 370) or RALP (n = 970) between 2013 and 2014. Demographics, cancer-related data, and perioperative laboratory data were evaluated. Postoperative AKI was determined according to the Kidney Disease: Improving Global Outcomes criteria. Operation and anesthesia time, estimated blood loss, amounts of administered fluids and transfused packed red blood cells, and the lengths of the postoperative intensive care unit and hospital stays were evaluated. Propensity score matching analysis was performed to reduce the influence of possible confounding variables and adjust for intergroup differences between the RRP and RALP groups.After performing 1:1 propensity score matching, the RRP and RALP groups included 307 patients, respectively. The operation time and anesthesia time in RALP were significantly longer than in the RRP group (both P < 0.001). However, the estimated blood loss and amount of administered fluids in RALP were significantly lower than in RRP (both P < 0.001). Also, RALP demonstrated a significantly lower incidence of transfusion and smaller amount of transfused packed red blood cells than RRP (both P < 0.001). Importantly, the incidence of AKI in RALP was significantly lower than in RRP (5.5% vs 10.4%; P = 0.044). Furthermore, the length of hospital stay in RALP was also significantly shorter (P < 0.001).The incidence of AKI after RALP is significantly lower than after RRP. RALP can therefore be a better surgical option than RRP in terms of decreasing the frequency of postoperative AKI.
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Affiliation(s)
- Eun-Young Joo
- From the Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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1490
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Llitjos JF, Daviaud F, Grimaldi D, Legriel S, Georges JL, Guerot E, Bedos JP, Fagon JY, Charpentier J, Mira JP. Ilio-psoas hematoma in the intensive care unit: a multicentric study. Ann Intensive Care 2016; 6:8. [PMID: 26782681 PMCID: PMC4717128 DOI: 10.1186/s13613-016-0106-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 01/04/2016] [Indexed: 02/06/2023] Open
Abstract
Background
Clinical features and outcomes of patients with spontaneous ilio-psoas hematoma (IPH) in intensive care units (ICUs) are poorly documented. The objectives of this study were to determine epidemiological, clinical, biological and management characteristics of ICU patients with IPH. Methods
We conducted a retrospective multicentric study in three French ICUs from January 2006 to December 2014. We included IPH diagnosed both at admission and during ICU stay. Surgery and embolization were available 24 h a day for each center, and therapeutic decisions were undertaken after pluridisciplinary discussion. All IPHs were diagnosed using CT scan. Results During this period, we identified 3.01 cases/1000 admissions. The mortality rate of the 77 included patients was 30 %. In multivariate analysis, we observed that mortality was independently associated with SAPS II (OR 1.1, 95 % CI [1.013–1.195], p = 0.02) and with the presence of hemorrhagic shock (OR 67.1, 95 % CI [2.6–1691], p = 0.01). We found IPH was related to anticoagulation therapy in 56 cases (72 %), with guideline-concordant reversal performed in 33 % of patients. We did not found any association between anticoagulant therapy type and outcome. Conclusion We found IPH is an infrequent disease, with a high mortality rate of 30 %, mostly related to anticoagulation therapy and usually affecting the elderly. Management of anticoagulation-related IPH includes a high rate of no reversal of 38 %.
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Affiliation(s)
- J F Llitjos
- Medical Intensive Care Unit, Cochin Hospital, Groupe Hospitalier Cochin Broca Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France. .,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, 75006, Paris, France.
| | - F Daviaud
- Medical Intensive Care Unit, Cochin Hospital, Groupe Hospitalier Cochin Broca Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, 75006, Paris, France
| | - D Grimaldi
- Medical Intensive Care Unit, Cochin Hospital, Groupe Hospitalier Cochin Broca Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, 75006, Paris, France
| | - S Legriel
- Intensive Care Unit, Hôpital de Versailles - Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France
| | - J L Georges
- Cardiology, Hôpital de Versailles - Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France
| | - E Guerot
- Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, 75006, Paris, France.,Medical Intensive Care Unit, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - J P Bedos
- Intensive Care Unit, Hôpital de Versailles - Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France
| | - J Y Fagon
- Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, 75006, Paris, France.,Medical Intensive Care Unit, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - J Charpentier
- Medical Intensive Care Unit, Cochin Hospital, Groupe Hospitalier Cochin Broca Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, 75006, Paris, France
| | - J P Mira
- Medical Intensive Care Unit, Cochin Hospital, Groupe Hospitalier Cochin Broca Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, 75006, Paris, France
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1491
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Mårtensson J, Jonsson N, Glassford NJ, Bell M, Martling CR, Bellomo R, Larsson A. Plasma endostatin may improve acute kidney injury risk prediction in critically ill patients. Ann Intensive Care 2016; 6:6. [PMID: 26762504 PMCID: PMC4712179 DOI: 10.1186/s13613-016-0108-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 01/05/2016] [Indexed: 01/11/2023] Open
Abstract
Background Breakdown of renal endothelial, tubular and glomerular matrix collagen plays a major role in acute kidney injury (AKI) development. Such collagen breakdown releases endostatin into the circulation. The aim of this study was to compare the AKI predictive value of plasma endostatin with two previously suggested biomarkers of AKI, cystatin C and neutrophil gelatinase-associated lipocalin (NGAL). Methods We studied 93 patients without kidney disease who had a first plasma sample obtained within 48 h of ICU admission. We identified risk factors for AKI within the population and designed a predictive model. The individual ability and net contribution of endostatin, cystatin C and NGAL to predict AKI were evaluated by the area under the receiver operating characteristics curve (AUC), likelihood-ratio test, net reclassification improvement (NRI) and integrated discrimination improvement (IDI). Results In total, 21 (23 %) patients experienced AKI within 72 h. A three-parameter model (age, illness severity score and early oliguria) predicted AKI with an AUC of 0.759 (95 % CI 0.646–0.872). Adding endostatin to the predictive model significantly (P = 0.04) improved the AUC to 0.839 (95 % CI 0.752–0.925). In addition, endostatin significantly improved risk prediction using the likelihood-ratio test (P = 0.005), NRI analysis (0.27; P = 0.04) and IDI analysis (0.07; P = 0.04). In contrast, adding cystatin C or NGAL to the three-parameter model did not improve risk prediction in any of the four analyses. Conclusions In this cohort of critically ill patients, plasma endostatin improved AKI prediction based on clinical risk factors, while cystatin C and NGAL did not. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0108-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Johan Mårtensson
- Section of Anaesthesia and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Solnavägen 1, 171 77, Solna, Sweden. .,Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, VIC, 3084, Australia.
| | - Niklas Jonsson
- Section of Anaesthesia and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Solnavägen 1, 171 77, Solna, Sweden
| | - Neil J Glassford
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, VIC, 3084, Australia
| | - Max Bell
- Section of Anaesthesia and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Solnavägen 1, 171 77, Solna, Sweden
| | - Claes-Roland Martling
- Section of Anaesthesia and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Solnavägen 1, 171 77, Solna, Sweden
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, VIC, 3084, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Preventive Medicine and Public Health, Monash University, The Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Anders Larsson
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, 751 85, Uppsala, Sweden
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1492
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Boyd JH, Fjell CD, Russell JA, Sirounis D, Cirstea MS, Walley KR. Increased Plasma PCSK9 Levels Are Associated with Reduced Endotoxin Clearance and the Development of Acute Organ Failures during Sepsis. J Innate Immun 2016; 8:211-20. [PMID: 26756586 DOI: 10.1159/000442976] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 12/02/2015] [Indexed: 12/22/2022] Open
Abstract
PURPOSE We have recently shown that PCSK9 reduces the clearance of endotoxin and is therefore a critical regulator of the innate immune response during infection. However, plasma PCSK9 levels during human sepsis and their relationship to outcomes are not known. Our objective was to determine the relationship between plasma PCSK9 levels and the rate of endotoxin clearance, and then correlate PCSK9 levels with the development of acute organ failures in a cohort of patients with sepsis. METHODS Using human hepatocyte cells, we determined the threshold at which PCSK9 is able to reduce Escherichia coli endotoxin uptake by cultured human hepatocytes. In a single-centre observational cohort at St. Paul's Hospital in Vancouver, Canada, we recruited 200 patients who activated our Emergency Department's sepsis protocol and measured plasma PCSK9 and lipid levels at triage and throughout the admission. Outcomes were the development of sepsis-induced cardiovascular or respiratory failure. RESULTS We reviewed the literature and determined that the normal human range of PCSK9 found in plasma is 170-220 ng/ml, while levels of 250 ng/ml and above reduced E. coli endotoxin clearance in cultured human hepatocytes. In septic patients, the median levels associated with new-onset respiratory and cardiovascular failure were 370 (250-500) and 380 (270-530) ng/ml, respectively, versus 270 (220-380) ng/ml in patients who did not go on to develop any organ failure (p = 0.003 and 0.005, respectively). CONCLUSIONS Plasma PCSK9 levels are greatly increased in sepsis. At normal levels, PCSK9 has no influence upon hepatocyte bacterial endotoxin clearance, but as levels rise, there is a progressive inhibition of clearance. During sepsis, PCSK9 levels are highly correlated with the development of subsequent multiple organ failure. Inhibition of PCSK9 activity is an attractive target for treating the spectrum of sepsis and septic shock.
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Affiliation(s)
- John H Boyd
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, B.C., Canada
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1493
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Jetton JG, Guillet R, Askenazi DJ, Dill L, Jacobs J, Kent AL, Selewski DT, Abitbol CL, Kaskel FJ, Mhanna MJ, Ambalavanan N, Charlton JR. Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates: Design of a Retrospective Cohort Study. Front Pediatr 2016; 4:68. [PMID: 27486571 PMCID: PMC4950470 DOI: 10.3389/fped.2016.00068] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 06/20/2016] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) affects ~30% of hospitalized neonates. Critical to advancing our understanding of neonatal AKI is collaborative research among neonatologists and nephrologists. The Neonatal Kidney Collaborative (NKC) is an international, multidisciplinary group dedicated to investigating neonatal AKI. The AWAKEN study (Assessment of Worldwide Acute Kidney injury Epidemiology in Neonates) was designed to describe the epidemiology of neonatal AKI, validate the definition of neonatal AKI, identify primary risk factors for neonatal AKI, and investigate the contribution of fluid management to AKI events and short-term outcomes. METHODS AND ANALYSIS The NKC was established with at least one pediatric nephrologist and neonatologist from 24 institutions in 4 countries (USA, Canada, Australia, and India). A Steering Committee and four subcommittees were created. The database subcommittee oversaw the development of the web-based database (MediData Rave™) that captured all NICU admissions from 1/1/14 to 3/31/14. Inclusion and exclusion criteria were applied to eliminate neonates with a low likelihood of AKI. Data collection included: (1) baseline demographic information; (2) daily physiologic parameters and care received during the first week of life; (3) weekly "snapshots"; (4) discharge information including growth parameters, final diagnoses, discharge medications, and need for renal replacement therapy; and (5) all serum creatinine values. ETHICS AND DISSEMINATION AWAKEN was proposed as human subjects research. The study design allowed for a waiver of informed consent/parental permission. NKC investigators will disseminate data through peer-reviewed publications and educational conferences. DISCUSSION The purpose of this publication is to describe the formation of the NKC, the establishment of the AWAKEN cohort and database, future directions, and a few "lessons learned." The AWAKEN database includes ~325 unique variables and >4 million discrete data points. AWAKEN will be the largest, most inclusive neonatal AKI study to date. In addition to validating the neonatal AKI definition and identifying risk factors for AKI, this study will uncover variations in practice patterns related to fluid provision, renal function monitoring, and involvement of pediatric nephrologists during hospitalization. The AWAKEN study will position the NKC to achieve the long-term goal of improving the lives, health, and well-being of newborns at risk for kidney disease.
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Affiliation(s)
- Jennifer G Jetton
- Stead Family Department of Pediatrics, Division of Nephrology, Dialysis and Transplantation, University of Iowa Children's Hospital , Iowa City, IA , USA
| | - Ronnie Guillet
- Department of Pediatrics, Division of Neonatology, University of Rochester Medical Center , Rochester, NY , USA
| | - David J Askenazi
- Department of Pediatrics, Division of Nephrology, University of Alabama at Birmingham , Birmingham, AL , USA
| | - Lynn Dill
- Department of Pediatrics, Division of Nephrology, University of Alabama at Birmingham , Birmingham, AL , USA
| | - Judd Jacobs
- Data Management Center, Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH , USA
| | - Alison L Kent
- Department of Neonatology, Centenary Hospital for Women and Children, Canberra Hospital, Australian National University Medical School , Canberra, ACT , Australia
| | - David T Selewski
- Department of Pediatrics and Communicable Diseases, Division of Nephrology, C.S. Mott Children's Hospital, University of Michigan , Ann Arbor, MI , USA
| | - Carolyn L Abitbol
- Department of Pediatrics, Division of Nephrology, Holtz Children's Hospital, University of Miami , Miami, FL , USA
| | - Fredrick J Kaskel
- Department of Pediatrics, Division of Nephrology, Children's Hospital at Montefiore, Albert Einstein , Bronx, NY , USA
| | - Maroun J Mhanna
- Department of Pediatrics, Division of Neonatology, MetroHealth Medical Center, Case Western Reserve University , Cleveland, OH , USA
| | - Namasivayam Ambalavanan
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham , Birmingham, AL , USA
| | - Jennifer R Charlton
- Department of Pediatrics, Division of Nephrology, University of Virginia , Charlottesville, VA , USA
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1494
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Corredor C, Thomson R, Al-Subaie N. Long-Term Consequences of Acute Kidney Injury After Cardiac Surgery: A Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth 2016; 30:69-75. [DOI: 10.1053/j.jvca.2015.07.013] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Indexed: 11/11/2022]
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1495
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Hauffe T, Krüger B, Bettex D, Rudiger A. Shock Management for Cardio-surgical Intensive Care Unit Patient: The Silver Days. Card Fail Rev 2016; 2:56-62. [PMID: 28785454 DOI: 10.15420/cfr.2015:27:2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Shock in cardio-surgical intensive care unit (ICU) patients requires prompt identification of the underlying condition and timely therapeutic interventions. Management during the first 6 hours, also referred to as "the golden hours", is of paramount importance to reverse the shock state and improve the patient's outcome. The authors have previously described a state-of-the-art diagnostic work-up and discussed how to optimise preload, vascular tone, contractility, heart rate and oxygen delivery during this phase. Ideally, shock can be reversed during this initial period. However, some patients might have developed multiple organ dysfunction, which persists beyond the first 6 hours despite the early haemodynamic treatment goals having been accomplished. This period, also referred to as "the silver days", is the focus of this review. The authors discuss how to reduce vasopressor load and how to minimise adrenergic stress by using alternative inotropes, extracorporeal life-support and short acting beta-blockers. The review incorporates data on fluid weaning, safe ventilation, daily interruption of sedation, delirium management and early rehabilitation. It includes practical recommendations in areas where the evidence is scarce or controversial. Although the focus is on cardio-surgery ICU patients, most of the considerations apply to critical ill patients in general.
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Affiliation(s)
- Till Hauffe
- Cardiosurgical Intensive Care Unit, Institute of Anaesthesiology, University Hospital Zurich, Switzerland
| | - Bernard Krüger
- Cardiosurgical Intensive Care Unit, Institute of Anaesthesiology, University Hospital Zurich, Switzerland
| | - Dominique Bettex
- Cardiosurgical Intensive Care Unit, Institute of Anaesthesiology, University Hospital Zurich, Switzerland
| | - Alain Rudiger
- Cardiosurgical Intensive Care Unit, Institute of Anaesthesiology, University Hospital Zurich, Switzerland
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1496
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Risk factors and prognostic factors of acute kidney injury in children: A retrospective study between 2003 and 2013. ACTA ACUST UNITED AC 2015; 35:785-792. [DOI: 10.1007/s11596-015-1508-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 10/14/2015] [Indexed: 10/22/2022]
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1497
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Grassner L, Marschallinger J, Dünser MW, Novak HF, Zerbs A, Aigner L, Trinka E, Sellner J. Nontraumatic spinal cord injury at the neurological intensive care unit: spectrum, causes of admission and predictors of mortality. Ther Adv Neurol Disord 2015; 9:85-94. [PMID: 27006696 DOI: 10.1177/1756285615621687] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Nontraumatic spinal cord injuries (NTSCIs) form a heterogeneous group of diseases, which may evolve into a life-threatening condition. We sought to characterize spectrum, causes of admission and predictors of death in patients with NTSCI treated at the neurological intensive care unit (NICU). METHODS We performed a retrospective observational analysis of NTSCI cases treated at a tertiary care center between 2001 and 2013. Among the 3937 NICU admissions were 93 patients with NTSCI (2.4%). Using multivariate logistic regression analysis, we examined predictors of mortality including demographics, etiology, reasons for admission and GCS/SAPS (Glasgow Coma Scale/Simplified Acute Physiology Score) scores. RESULTS Infectious and inflammatory/autoimmune causes made up 50% of the NTSCI cases. The most common reasons for NICU admission were rapidly progressing paresis (49.5%) and abundance of respiratory insufficiency (26.9%). The mortality rate was 22.6% and 2.5-fold higher than in the cohort of all other patients treated at the NICU. Respiratory insufficiency as the reason for NICU admission [odds ratio (OR) 4.97, 95% confidence interval (CI) 1.38-17.9; p < 0.01], high initial SAPS scores (OR 1.04; 95% CI 1.003-1.08; p = 0.04), and the development of acute kidney injury throughout the stay (OR 7.25, 1.9-27.5; p = 0.004) were independent risk factors for NICU death. CONCLUSIONS Patients with NTSCI account for a subset of patients admitted to the NICU and are at risk for adverse outcome. A better understanding of predisposing conditions and further knowledge of management of critically ill patients with NTSCI is mandatory.
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Affiliation(s)
- Lukas Grassner
- Center for Spinal Cord Injuries, BG Trauma Center Murnau, Germany Institute of Molecular Regenerative Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Julia Marschallinger
- Institute of Molecular Regenerative Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Martin W Dünser
- Department of Anesthesiology, Perioperative Medicine and General Intensive Care Medicine, Salzburg University Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Helmut F Novak
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Alexander Zerbs
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Ludwig Aigner
- Institute of Molecular Regenerative Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Johann Sellner
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Ignaz-Harrer-Str. 79, A-5020 Salzburg, Austria
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1498
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Nishimura H, Enokida H, Kawahira S, Kagara I, Hayami H, Nakagawa M. Acute Kidney Injury and Rhabdomyolysis After Protobothrops flavoviridis Bite: A Retrospective Survey of 86 Patients in a Tertiary Care Center. Am J Trop Med Hyg 2015; 94:474-9. [PMID: 26643529 DOI: 10.4269/ajtmh.15-0549] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 11/03/2015] [Indexed: 11/07/2022] Open
Abstract
Acute kidney injury (AKI) is the main cause of death for victims of hematoxic snakebites. A few studies have described improvement in AKI rates in snakebite cases, but the reasons for the improvement have not been investigated. Eighty-six patients with Protobothrops flavoviridis bites admitted to a single center from January 2003 through March 2014 were included in the study. Clinical variables, including age, sex, blood pressure (BP), and serum creatinine (S-Cre), on admission were compared between patients with and without AKI. One patient died of disseminated intravascular coagulation following AKI (mortality rate 1.1%). Six patients developed AKI with rhabdomyolysis. Systolic BP, S-Cre, serum creatine kinase, white blood cell count, and platelet count differed significantly between the AKI and non-AKI groups (P = 0.01). Three of the six patients were physically challenged to a degree that made it difficult for them to move or communicate, and these difficulties likely exacerbated the severity of snakebite complications. Our study demonstrated that the risk of snakebite-induced AKI for physically challenged patients was high. To further reduce mortality due to snakebite-induced AKI, we need to make it possible for physically challenged patients to receive first aid sooner.
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Affiliation(s)
- Hiroaki Nishimura
- Division of Blood Purification, Kagoshima Prefectural Ohshima Hospital, Kagoshima, Japan; Department of Urology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan; Blood Purification Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Hideki Enokida
- Division of Blood Purification, Kagoshima Prefectural Ohshima Hospital, Kagoshima, Japan; Department of Urology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan; Blood Purification Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Shuichirou Kawahira
- Division of Blood Purification, Kagoshima Prefectural Ohshima Hospital, Kagoshima, Japan; Department of Urology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan; Blood Purification Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Ichiro Kagara
- Division of Blood Purification, Kagoshima Prefectural Ohshima Hospital, Kagoshima, Japan; Department of Urology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan; Blood Purification Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Hiroshi Hayami
- Division of Blood Purification, Kagoshima Prefectural Ohshima Hospital, Kagoshima, Japan; Department of Urology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan; Blood Purification Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Masayuki Nakagawa
- Division of Blood Purification, Kagoshima Prefectural Ohshima Hospital, Kagoshima, Japan; Department of Urology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan; Blood Purification Center, Kagoshima University Hospital, Kagoshima, Japan
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1499
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Abstract
Acute kidney injury (AKI) - an abrupt deterioration in renal function - causes a rise in serum creatinine (SCr) or fall in urine output. It is common, occurring in up to 20% of hospital admissions. Importantly, even small rises in SCr are associated with increased risk of death and longer hospital stays. A 2009 National Confidential Enquiry into Patient Outcome and Death report found that a proportion of AKI in secondary care was avoidable. In addition, management of established AKI was 'good' less than half the time. In practice, AKI represents a heterogeneous group of conditions, encompassing impairments in both kidney structure and function. Delivering disease-specific treatment early in the course of AKI may improve outcomes. The provision of best-practice care for all will rely on a better understanding of risk, and frameworks of care that can be applied across a diverse patient group.
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Affiliation(s)
| | - Chris Laing
- Department of Nephrology, Royal Free London NHS Foundation Trust, London, UK
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1500
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Monseu M, Gand E, Saulnier PJ, Ragot S, Piguel X, Zaoui P, Rigalleau V, Marechaud R, Roussel R, Hadjadj S, Halimi JM. Acute Kidney Injury Predicts Major Adverse Outcomes in Diabetes: Synergic Impact With Low Glomerular Filtration Rate and Albuminuria. Diabetes Care 2015; 38:2333-40. [PMID: 26512039 DOI: 10.2337/dc15-1222] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Accepted: 09/24/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Subjects with diabetes are prone to the development of cardiovascular and noncardiovascular complications. In separate studies, acute kidney injury (AKI), albuminuria, and low estimated glomerular filtration rate (eGFR) were shown to predict adverse outcomes, but, when considered together, their respective prognostic value is unknown. RESEARCH DESIGN AND METHODS Patients with type 2 diabetes consecutively recruited in the SURDIAGENE cohort were prospectively followed up for major diabetes-related events, as adjudicated by an independent committee: death (with cause), major cardiovascular events (myocardial infarction, stroke, congestive heart failure, amputation, and arterial revascularization), and renal failure (i.e., sustained doubling of serum creatinine level or end-stage renal disease). RESULTS Intrahospital AKI occurred in 411 of 1,371 patients during the median follow-up period of 69 months. In multivariate analyses, AKI was significantly associated with cardiovascular and noncardiovascular death, including cancer-related death. In multivariate analyses, AKI was a powerful predictor of major adverse cardiovascular events, heart failure requiring hospitalization, myocardial infarction, stroke, lower-limb amputation or revascularization, and carotid artery revascularization. AKI, eGFR, and albuminuria, even when simultaneously considered in multivariate models, predicted all-cause and cardiovascular deaths. All three renal biomarkers were also prognostic of most adverse outcomes and of the risk of renal failure. CONCLUSIONS AKI, low eGFR, and elevated albuminuria, separately or together, are compelling biomarkers of major adverse outcomes and death in diabetes.
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Affiliation(s)
- Mathilde Monseu
- Université de Poitiers, CIC1402, Poitiers, France Centre d'Investigation Clinique, CHU de Poitiers, Poitiers, France INSERM, CIC1402, Poitiers, France Service d'Endocrinologie, CHU de Poitiers, Pôle DUNE, Poitiers, France
| | - Elise Gand
- Service d'Endocrinologie, CHU de Poitiers, Pôle DUNE, Poitiers, France
| | - Pierre-Jean Saulnier
- Université de Poitiers, CIC1402, Poitiers, France Centre d'Investigation Clinique, CHU de Poitiers, Poitiers, France INSERM, CIC1402, Poitiers, France
| | - Stéphanie Ragot
- Université de Poitiers, CIC1402, Poitiers, France Centre d'Investigation Clinique, CHU de Poitiers, Poitiers, France INSERM, CIC1402, Poitiers, France
| | - Xavier Piguel
- Service d'Endocrinologie, CHU de Poitiers, Pôle DUNE, Poitiers, France
| | - Philippe Zaoui
- Service Néphrologie, Dialyse et Transplantation, CHU de Grenoble, La Tronche, France Faculté de Médecine, Domaine de la Merci, Université Joseph Fourrier, Grenoble, France
| | - Vincent Rigalleau
- Service d'Endocrinologie, Diabétologie, Maladies Métaboliques et Nutrition, CHU de Bordeaux, Pessac, France
| | - Richard Marechaud
- Service d'Endocrinologie, CHU de Poitiers, Pôle DUNE, Poitiers, France Faculté de Médecine et Pharmacie, Université de Poitiers, Poitiers, France
| | - Ronan Roussel
- Université Paris 7 Denis Diderot, U695, Paris, France Service d'Endocrinologie, Diabétologie, Nutrition, Groupe Hospitalier Bichat Claude Bernard, Assistance Public-Hôpitaux de Paris, Paris, France
| | - Samy Hadjadj
- Université de Poitiers, CIC1402, Poitiers, France Centre d'Investigation Clinique, CHU de Poitiers, Poitiers, France INSERM, CIC1402, Poitiers, France Service d'Endocrinologie, CHU de Poitiers, Pôle DUNE, Poitiers, France Faculté de Médecine et Pharmacie, Université de Poitiers, Poitiers, France INSERM, U1082, Poitiers, France
| | - Jean-Michel Halimi
- Service de Néphrologie, CHU de Tours, Tours, France Université François-Rabelais, EA4245, Faculté de Médecine, Tours, France
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